Citations in New York
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in New York.
Statistics for New York (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in New York
A resident with cognitive impairment and multiple comorbidities experienced an unwitnessed fall resulting in a left eye hematoma. The incident, which was documented by staff and led to a hospital transfer, was not reported to the Department of Health as required by policy and regulation, due to the absence of suspected abuse according to the DON and Administrator.
A resident with serious infections did not receive or have documented several scheduled IV antibiotic doses, as required by physician orders. MAR entries were left blank for multiple administrations, and there was no evidence in progress notes or provider notification regarding the missed doses. Staff interviews revealed confusion about responsibility for IV medication administration and documentation, and facility leadership confirmed that blank MAR entries constituted medication errors, but no investigation or provider notification was documented.
A resident receiving IV vancomycin for serious infections did not have required vancomycin trough levels drawn as ordered, and the only recorded trough was not performed at the correct time. Staff interviews revealed confusion about lab scheduling and timing, and there was no documentation that the necessary labs were completed or communicated to the pharmacy or consultant pharmacist.
A resident admitted for respite care with multiple comorbidities received four incorrect doses of morphine due to a transcription error and incomplete verification process. The resident became unresponsive with unstable vital signs, but staff did not provide interventions to reverse the opioid effects or consistently monitor the resident's condition. Communication failures led to delays in notifying the family, hospice, and facility leadership about the error, and the resident died without documented evidence of appropriate assessment or intervention.
A resident with multiple comorbidities was administered four incorrect doses of morphine sulfate due to a transcription error during order entry, resulting in a total of 80 mg over 12 hours. The error was not identified by the triple check process or by staff administering the medication, and the resident, who had not previously received morphine, became unresponsive and died. Staff did not follow medication administration and error reporting policies, and concerns raised by the family regarding the resident's condition and possible use of Narcan were not acted upon.
Two residents with intact cognition reported allegations of sexual abuse by a CNA, including inappropriate comments and unwanted touching during care. Despite these reports, the facility did not conduct thorough investigations, failed to assess the residents physically or psychosocially, and allowed the CNA to return to work with access to all residents. Leadership did not report the incidents or inform the medical director in a timely manner.
Two residents with intact cognition reported inappropriate and potentially abusive contact by a CNA, including unwanted touching and inappropriate comments. Facility leadership did not report these allegations to law enforcement or the state health department, nor did they conduct required investigations, as they did not believe the incidents constituted abuse. The facility's policy lacked guidance on reporting to law enforcement, and no physical or psychosocial assessments were completed for the affected residents.
Two residents with intact cognition reported inappropriate and distressing care by a CNA, including intimate care against their wishes and inappropriate comments. Despite facility policy requiring immediate reporting and investigation of abuse allegations, leadership dismissed the concerns without thorough inquiry or documentation, and no comprehensive investigation was conducted.
Surveyors found that multiple residents did not receive their medications within the prescribed time frames, and medical providers were not notified of these delays as required by facility policy. LPNs cited heavy workloads, computer issues, and resident unavailability as reasons for late administration, and staff interviews confirmed that documentation of provider notification was lacking.
Two residents with cognitive impairment and known elopement risks were able to exit the facility unsupervised due to lapses in required one-to-one supervision and failures in the wander guard alarm system. In both cases, staff left the residents unattended without arranging coverage, and the facility's alarm system did not alert staff to the exits. There was also a lack of documentation showing that ordered safety interventions were implemented.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or injuries of unknown source were reported to the New York State Department of Health within the required timeframe. Specifically, a resident with a history of coronary artery disease, diabetes mellitus, and non-Alzheimer's dementia, who was moderately cognitively impaired and dependent on staff for most activities of daily living, experienced an unwitnessed fall from bed. The incident resulted in a hematoma and swelling around the left eye, and the resident was unable to explain how the fall occurred. The event was documented by both nursing and physician staff, and the resident was transferred to the hospital for further evaluation. Despite the facility's policy requiring immediate reporting of such incidents, the event was not reported to the Department of Health. Interviews with the DON and the Administrator revealed that the incident was not reported because there was no suspicion of abuse and the resident was sent to the hospital. The facility's failure to report the unwitnessed fall with injury, as required by federal and state regulations and the facility's own policy, constituted the deficiency identified during the survey.
Failure to Administer and Document IV Antibiotics as Ordered
Penalty
Summary
A deficiency was identified when a resident with diagnoses including osteomyelitis of the thoracic vertebrae, local skin infection, and sepsis did not receive several prescribed intravenous antibiotic doses. Physician orders required administration of cefepime and vancomycin every 12 hours, but the Medication Administration Record (MAR) showed blank entries for multiple scheduled doses, indicating they were either not given or not documented. There was no evidence in the nursing progress notes of missed doses or provider notification regarding these omissions. Interviews with nursing staff revealed confusion and inconsistency regarding responsibility for intravenous medication administration and documentation. LPNs and RNs described different processes for being alerted to medication times, and some staff were unsure why MAR entries were left blank. Supervisory staff acknowledged that a blank MAR box meant the medication was unaccounted for, and that this constituted a medication error. However, there was no documentation of any investigation into the missing administrations, nor was there evidence that the provider was notified as required by facility policy. The physician responsible for the resident's care confirmed that they were not notified of any missed antibiotic doses, which they considered a significant medication error. Facility leadership, including the DON and Assistant DON, stated that all MAR entries should be completed and that missed or undocumented doses should be investigated and reported. Despite this, no such actions were documented, and the missed doses remained unaccounted for.
Failure to Obtain Timely and Accurate Vancomycin Trough Levels
Penalty
Summary
The facility failed to ensure timely and accurate laboratory services for one resident who was receiving intravenous vancomycin for osteomyelitis, discitis, and sepsis. Physician orders required regular monitoring of vancomycin trough levels and other laboratory tests to assess the effectiveness and safety of the antibiotic therapy. Despite these orders, there was no documented evidence that the required vancomycin trough levels were obtained on the specified dates, and the only recorded trough was not performed at the appropriate time relative to the dosing schedule. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, revealed that laboratory draws were scheduled on specific days of the week, and there was confusion or lack of clarity regarding the timing of the vancomycin trough draws. The registered nurses were responsible for drawing blood from the resident's peripherally inserted central catheter, but the records did not show that the required labs were completed as ordered. The pharmacy and consultant pharmacist were not contacted with the necessary lab results, and the facility failed to communicate effectively regarding the resident's laboratory needs. The failure to obtain timely and accurate vancomycin trough levels was confirmed through record review and staff interviews. The physician stated that the trough levels should have been drawn every three days and prior to the next scheduled dose, and that delays or missed draws were not acceptable. The lack of appropriate laboratory monitoring was not explained by the staff, and there was no documentation to support that the required tests were performed as ordered.
Failure to Prevent Neglect and Respond to Opioid Overdose
Penalty
Summary
A facility failed to protect a resident from neglect, resulting in the administration of four incorrect doses of morphine sulfate totaling 80 milligrams over a 12-hour period. The resident, who was admitted for respite care with diagnoses including dementia, end-stage renal disease, and atrial fibrillation, had not previously received morphine at home. The error originated from a transcription mistake during the medication reconciliation process, where three out of five morphine orders were entered incorrectly and the facility's triple check system was not fully completed, lacking a third verification signature. The error was discovered only after a nurse questioned the order, at which point the incorrect order was discontinued and a corrected order was entered. Following the medication error, the resident became lethargic and unresponsive, with unstable vital signs including low blood pressure and oxygen saturation. Despite these changes, there was no documented evidence that the facility provided interventions to reverse the effects of the opioid overdose, such as administering naloxone (Narcan), even after the family inquired about it. Additionally, there was a lack of documented monitoring, assessment, or treatment for the resident's decline after the error was identified. Vital signs and nursing assessments were not consistently recorded, and there was no evidence of physician oversight or coordination with hospice regarding the medication error. Communication failures further contributed to the deficiency. The resident's representative was not notified of the medication error until after the resident's condition had significantly deteriorated. Hospice was not informed of the medication error, and attempts to contact hospice during the resident's decline were unsuccessful due to incorrect contact information. Key facility leadership, including the Director of Nursing and Administrator, were not promptly informed of the incident, and staff interviews revealed a lack of awareness and documentation regarding the resident's condition and the actions taken. The resident ultimately expired without documented evidence of appropriate monitoring or intervention following the overdose.
Removal Plan
- Post Hospice contact information in each nursing unit and include on the face sheet for residents actively on Hospice.
- Make the contact for Community Hospice visible at accessible locations such as a nursing station on each resident unit.
- Ensure that for all residents enrolled in Hospice services, the contact number for Community Hospice is visible and accessible under contacts on the residents' face sheets in both electronic and paper charts.
- Update medication error reporting policy to require the Physician/Nurse Practitioner, upon notification of medication error, to provide direction for monitoring, duration of monitoring, and expected follow up communication.
- Require documentation of the nature of the incident, individuals notified (including family and hospice as applicable), actions taken, orders received, results of continued monitoring, assessments, and communication.
- In-service all on-call Physicians and Nurse Practitioners regarding high-risk medications and review of electronic ordering for safe dosing.
- Educate all nursing staff, including agency staff, by the nursing educator/designee on the updated Medication Error Reporting policy, including directions on provider and family notification as well as resident monitoring and documentation requirements.
- Use education sign-in sheets to document that in-house and agency nurses were educated; educate remaining agency nurses if they return to the facility.
- Compare transcribed orders with original provider order for accuracy; complete and document checks in the paper chart for the next two consecutive shifts.
- Educate all nursing staff (including agency staff) by the nurse educator, supervision, or designee regarding medication reconciliation, medication transcription, triple check, and safe medication administration practices.
- In-service all in-house and agency nurses regarding the abuse/neglect and mistreatment policy, with a special focus on potential neglect related to medication errors and lack of monitoring, assessment, and documentation related to change in condition.
Significant Medication Error Resulting in Resident Death
Penalty
Summary
A significant medication error occurred when a resident admitted for respite care with diagnoses including dementia, end-stage renal disease, and atrial fibrillation, was administered four incorrect doses of morphine sulfate, totaling 80 milligrams over a 12-hour period. The original hospice order specified morphine 5 mg by mouth every four hours as needed, but during the admission process, a transcription error resulted in the order being entered as 20 mg per dose. This error was not identified during the triple check process or by subsequent staff administering the medication. Multiple staff members, including registered nurses and licensed practical nurses, were involved in the medication administration and order entry process. The error was not questioned until after the fourth dose had been given, at which point a nurse reviewed the medication and brought the issue to the attention of supervisory staff. Interviews revealed that staff assumed the order was correct, particularly because the resident was on hospice care, and did not verify the appropriateness of the dose or question the high dosage of morphine being administered. The resident, who had not previously received morphine at home, became unresponsive and died following the administration of the incorrect doses. Family members raised concerns about the resident's condition and the potential use of Narcan, but were advised by facility staff and a physician that Narcan was not appropriate or effective at that time. The facility's policies on medication administration and error reporting were not followed, and the error was only identified after significant harm had occurred.
Removal Plan
- Narcotic orders were reviewed for ongoing appropriateness and safety by Medical Director #1.
- Narcotic orders were reviewed for ongoing appropriateness and safety. Immediate education was provided to Physician #1 and Licensed Practical Nurse #1, and the order was amended by Chief Nursing Officer #1 and Medical Director #1.
- All active medication orders were reviewed by the consultant pharmacists and medical director for ongoing appropriateness and safety.
- Administrator #1 worked with electronic ordering system creators to enable a feature to run reports that reflected ordering errors for closer daily monitoring.
- All on-call physicians and nurse practitioners were in serviced by the Medical Director #1 regarding high-risk medications and review of electronic ordering for safe dosing.
- The remaining physicians and nurse practitioners were inserviced.
- ‘Transcription of Orders' policy was developed to include information regarding medication reconciliation as well as the triple check process.
- Compared transcribed orders with original provider order for accuracy. Checks were completed and documented in the paper chart for the next two consecutive shifts.
- All nursing including agency staff will be educated by nursing educator/designee prior to start of shift on the updated Medication Error Reporting policy, which includes directions on provider and family notification as well as resident monitoring and documentation requirements.
- Education Sign-In Sheets titled Transcription- Triple Check- Medication Reconsolidation, Transfer report - hand off sheet, Neglect related to Resident Monitoring - Education sign-in sheets documented in house nurses and agency nurses educated. Agency nurses left to educate if they return to the facility.
- Chief Nursing Officer #1 stated that the medication nurse was educated regarding an end date needed for the order and printing orders to place in the chart to begin the triple check process.
- Medical Director #1, and/or Administrator #1 and/or Chief Nursing Officer #1 would check orders from the previous day.
- Nurse Managers were responsible for completing audits on triple check and would bring audit results to Quality Assurance monthly meetings.
- Surveyors verified the facility conducted a daily 24-hour look back on all new medication orders by Director of Nursing #1 or designee.
- Interviews with all parties responsible for these barrier checks showed they were aware of their required responsibilities.
Failure to Protect Residents from Alleged Sexual Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to protect residents from alleged sexual abuse, resulting in Immediate Jeopardy for two residents with intact cognition. Both residents reported inappropriate actions by a Certified Nursing Assistant (CNA), including sexually inappropriate comments and unwanted touching during personal care. Despite these allegations, there was no documented evidence that a thorough investigation was initiated, nor were the residents assessed by a registered nurse or provided with a psychosocial evaluation after expressing fear and discomfort. One resident, diagnosed with multiple sclerosis, protein calorie malnutrition, and pseudobulbar affect, reported that a male CNA made a sexually inappropriate comment and applied cream to intimate areas without proper consent. The resident had previously requested female caregivers, but this preference was not documented or honored. The incident was reported to facility leadership, but the CNA was only suspended for three days without a comprehensive investigation and was later allowed to return to work with access to all residents. There was no documentation of a physical or psychosocial assessment for the resident following the incident. A second resident, with diagnoses including type 2 diabetes, depression, and anxiety disorder, reported that the same CNA took an unusually long time wiping their genital area, making them feel unsafe. This concern was reported to another CNA and a registered nurse supervisor, but no formal investigation or assessment was conducted. The resident was transferred to another room, but there was no evidence of a registered nurse assessment or psychosocial evaluation. Facility leadership decided not to report or investigate the allegation, citing a lack of perceived sexual abuse, and the medical director was not informed until much later.
Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made. This deficiency was identified for two residents who reported allegations of inappropriate and potentially abusive behavior by a certified nursing assistant. The facility did not document evidence that these allegations were reported to local law enforcement or the New York State Department of Health as required by regulation. One resident, with a history of multiple sclerosis, protein-calorie malnutrition, and pseudobulbar affect, reported that a male certified nursing assistant made inappropriate comments about their shaved vaginal area and applied cream to their buttocks despite the resident's request to self-apply. The resident delayed reporting the incident due to embarrassment, and the family member subsequently informed facility leadership. Despite the resident and family expressing concerns about safety, the facility leadership determined within two hours that there was no evidence of abuse and did not report the incident to authorities. The facility's policy did not include guidance on reporting to law enforcement, and the staff involved did not consider the incident to be sexual abuse. A second resident, with diagnoses including type 2 diabetes, depression, and anxiety disorder, reported that the same certified nursing assistant rubbed their genital area in a manner that made them feel violated. The resident was visibly upset and reported the incident to another staff member, who escalated it to a supervisor. However, the facility did not document any report to authorities or conduct a formal investigation, as leadership did not believe the incident constituted abuse. Interviews with facility leadership and the medical director revealed a lack of awareness and appropriate response to the allegations, and no physical or psychosocial assessments were completed for the residents involved.
Failure to Investigate Alleged Sexual Abuse Incidents
Penalty
Summary
The facility failed to thoroughly and promptly investigate allegations of sexual abuse involving two residents, resulting in a deficiency identified during an abbreviated survey. According to the facility's abuse prevention policy, all allegations of abuse must be immediately reported and investigated, including obtaining statements from staff, witnesses, and residents, as well as reviewing medical and employee records. However, in both cases, there was no documented evidence that a comprehensive investigation was initiated to rule out abuse, neglect, or mistreatment. One resident, with a history of multiple sclerosis and intact cognition, reported that a male CNA provided intimate care despite their request for a female caregiver and made inappropriate comments regarding the resident's body. The resident delayed reporting the incident due to embarrassment, but when the family member informed facility leadership, the Assistant Director of Nursing dismissed the allegation, believing the resident was fabricating the story, and did not pursue further investigation. The administrator also concluded within two hours that there was no evidence of abuse based on family input, without conducting a thorough inquiry. A second resident, also with intact cognition and a care plan identifying risk for psychosocial distress, reported discomfort and distress after a CNA allegedly took an unusually long time providing care to their genital area. The resident was visibly upset and requested a room change to avoid further contact with the CNA. Although the concern was reported to nursing and social work staff, no further questions were asked, and the Director of Nursing decided not to report or investigate the allegation, concluding it did not constitute sexual abuse. The administrator similarly determined no investigation was necessary. The medical director later stated that all allegations of abuse should be reported and investigated immediately.
Failure to Administer Medications Timely and Notify Providers
Penalty
Summary
Surveyors identified that the facility failed to ensure residents received medications in accordance with provider orders and professional standards of practice. Observations, interviews, and record reviews revealed that four residents did not receive their scheduled medications within the prescribed time frames. The facility's policy required medications to be administered as ordered, and for staff to notify medical providers if medications were given late. However, medications were consistently administered late across various units, and there was no documented evidence that medical providers were notified of these delays. Specific incidents included residents with complex medical conditions such as fractures, dementia, hypertensive crises, heart failure, and anxiety disorders. For example, one resident with hypertension and dementia was scheduled to receive a Lidocaine patch and Metoprolol at specific times, but these were administered late. Another resident with heart failure and respiratory issues received Bumetanide later than ordered, and questioned the nurse about the inconsistent timing. In each case, the responsible LPNs acknowledged the delays, citing reasons such as heavy medication passes, computer system issues, and residents being unavailable due to appointments or meetings. Despite staff awareness of the need to notify medical providers about late medication administration, there was no documentation of such notifications in the electronic medical record. Interviews with nursing staff confirmed that while they sometimes verbally informed providers, they often forgot to document these communications. The facility also relied heavily on agency nurses, and staff reported that high workload and frequent interruptions contributed to the delays in medication administration.
Failure to Prevent Elopement and Inadequate Supervision of At-Risk Residents
Penalty
Summary
The facility failed to ensure that residents at risk for elopement received adequate supervision and that the environment was free from accident hazards, as evidenced by two separate incidents involving residents with documented elopement risks. In the first case, a resident with diagnoses including anxiety disorder, cerebral infarction, and schizoaffective disorder, and with a history of wandering and elopement attempts, was placed on one-to-one supervision. Despite this, the assigned Patient Care Assistant left the resident unattended to take a dinner break without arranging for coverage, and the resident was able to exit the facility undetected. The facility's wander guard system did not alarm, and the resident was later found at a nearby bus station. Staff interviews confirmed that the resident was known to be at high risk for elopement and that one-to-one supervision required the staff member to remain within arm's reach at all times, which was not followed in this instance. In the second case, another resident with diagnoses including dementia with mood disturbance, agitation, and Parkinson's disease, and with severely impaired cognition and wandering behaviors, also eloped from the facility on two separate occasions. The resident was assessed as an elopement risk and had a wander guard in place. After the first elopement, interventions such as 30-minute visual checks and one-to-one supervision at night were ordered, but there was no documented evidence that these interventions were implemented. The resident subsequently eloped again, exiting through the front entrance without staff detection, and was found by police walking on a nearby street. Staff interviews revealed that the wander guard system did not alarm or secure the elevators or exit doors at the time, and there was a lack of internal cameras to monitor resident movement. Throughout both incidents, facility staff, including the DON and Administrator, acknowledged that the required supervision protocols were not followed and that the wander guard system was not fully integrated with all exits and elevators. Staff responsible for one-to-one supervision left residents unattended without arranging for relief, and there was a lack of documentation to show that required safety interventions were consistently implemented. The facility's policies on elopement prevention and one-to-one supervision were not adhered to, directly contributing to the residents' ability to leave the premises unsupervised.
Some of the Latest Corrective Actions taken by Facilities in New York
- Instated hall monitors on all three shifts to prevent residents from entering other residents’ rooms (K - F0610 - NY) (K - F0600 - NY)
- Provided facility-wide staff education on abuse recognition, response, protection steps, and reporting through online modules with competency verification (K - F0610 - NY) (K - F0600 - NY)
Failure to Implement Effective Bowel Management Protocol Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. The resident, who had diagnoses including multiple sclerosis, depression, generalized weakness, hypothyroidism, and a history of constipation, did not have a documented bowel movement for an extended period. Despite having physician orders for as needed laxatives, there was no documented evidence that these medications were administered during the period of no bowel movements. The facility's electronic medical record system was programmed to generate alerts and reports for absent bowel movements, but there was no evidence that these alerts and reports were reviewed or acted upon by staff during the relevant timeframes. The resident was eventually hospitalized after developing fever and tachycardia, where imaging revealed a severe rectal stool burden and stercoral colitis, requiring manual disimpaction. Upon return from the hospital, the resident again had no documented bowel movement for several days, and as needed bowel medications were not administered until several days later. Interviews with nursing staff and facility leadership revealed inconsistent understanding and implementation of bowel management protocols, with some staff unaware of the resident's condition or the need to act on bowel movement alerts. The facility did not have a written bowel management protocol specifying monitoring timeframes or parameters for administering as needed medications, and staff relied on inconsistent practices for reviewing and acting on bowel movement reports. Documentation showed that the resident was repeatedly listed on bowel movement reports as having no bowel movement, but there was no evidence of follow-up or intervention. Staff interviews indicated confusion about the frequency and use of bowel movement reports and alerts, and some staff were not aware of the resident's prolonged constipation or the need to notify providers. The lack of a clear, written bowel management protocol and failure to act on documented alerts and reports resulted in actual harm to the resident, as well as a likelihood of serious harm for other residents.
Removal Plan
- The facility provided a copy of the defined Bowel Management Regimen policy and procedure.
- The bowel regimen policy was observed in binders on each residential unit along with current bowel movement reports.
- The facility provided supporting documentation for nursing staff educated on the formal bowel management policy and procedure with an attestation that all remaining nursing staff would receive education prior to their next scheduled shift.
- A list of all facility residents who did not have a documented bowel movement in three days was provided.
- Supporting evidence of as needed medications offered and provided was reviewed with no identified concerns.
Failure to Investigate and Protect Residents Following Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for three of eight residents reviewed. Specifically, on three separate occasions, a resident with severe cognitive impairment was witnessed by visitors and/or staff engaging in sexually inappropriate behavior with two other residents who also lacked capacity to consent. There was no documented evidence that these incidents were thoroughly investigated to determine if abuse occurred or that measures were put in place to protect residents from further abuse during the investigation process. The facility's policy required immediate reporting and thorough investigation of any suspected abuse, including obtaining witness statements, assessing the residents involved, and notifying appropriate supervisory staff. However, for the incidents in question, documentation was incomplete or missing. For example, one incident report was not completed, and the investigations that were provided included only summaries and unsigned witness statements. There was no evidence that family members who witnessed the events were interviewed, and staff who were present were not always asked to provide statements. Additionally, there was no documentation of how abuse was ruled out or what interim protective measures were implemented for other residents during the investigation. Interviews with staff and administration revealed inconsistencies in the reporting and investigation process. Some staff were told not to document the incidents, and the Director of Nursing acknowledged that investigations were incomplete, with missing witness statements and assessments. The Administrator and Director of Nursing were not always notified of incidents in a timely manner, and there was uncertainty about whether families were informed. The lack of thorough investigation and documentation resulted in Immediate Jeopardy and Substandard Quality of Care for the residents involved.
Removal Plan
- Facility hall monitors were instated for all three shifts to ensure residents stayed out of other resident rooms
- All residents in the facility were assessed for aggression risk
- Resident #1 was placed on a 1:1
- All staff currently working in the facility were educated on abuse, responding to abuse, signs of abuse, steps to take to protect residents, and reporting abuse
- Staff education was completed online, and multiple department facility staff working were interviewed and were able to demonstrate understanding of the education
Failure to Protect Residents from Abuse and Inadequate Incident Response
Penalty
Summary
Multiple incidents occurred in which residents with severe cognitive impairment and a history of wandering were found in compromising situations with another resident, including being found in bed together without pants or with clothing removed and exposed. In several cases, staff or family members discovered the incidents, and the involved residents were separated and placed on increased monitoring. Despite these events, there was no documented evidence that a registered nurse assessed the residents immediately following the incidents, even when complaints of pain or signs of distress were present. Additionally, there was no documentation that the residents' families were notified of the incidents as required. Care plans for the residents involved were not updated to reflect the risk or occurrence of abuse or potential victimization, and interventions were limited to increased monitoring without addressing the underlying risks. Social work and psychosocial assessments were not documented following the incidents, and medical providers were not consistently notified or involved in post-incident evaluations. Staff interviews revealed that similar incidents had occurred previously and were sometimes not reported or investigated, and that interventions such as alarm mats were ineffective in preventing recurrence. Facility leadership, including the DON and Administrator, were not consistently notified of all incidents, and investigations were incomplete or delayed. The facility did not report the incidents to the state health department, citing a lack of evidence of injury or mental anguish, despite multiple staff and witness accounts indicating resident distress and inability to consent. The lack of timely assessment, reporting, care plan updates, and comprehensive investigation contributed to the deficiency in protecting residents from abuse and neglect.
Removal Plan
- Facility hall monitors were instated for all three shifts to ensure residents stayed out of other resident rooms
- All residents in the facility were assessed for aggression risk
- Resident #1 was placed on continuous 1:1
- All staff currently working in the facility were educated on abuse, responding to abuse, signs of abuse, steps to take to protect residents, and reporting abuse
- Staff education was completed online, and multiple department facility staff working were interviewed and were able to demonstrate understanding of the education
Significant Medication Error Resulting in Resident Death
Penalty
Summary
A significant medication error occurred when a resident admitted for respite care with diagnoses including dementia, end-stage renal disease, and atrial fibrillation, was administered four incorrect doses of morphine sulfate, totaling 80 milligrams over a 12-hour period. The original hospice order specified morphine 5 mg by mouth every four hours as needed, but during the admission process, a transcription error resulted in the order being entered as 20 mg per dose. This error was not identified during the triple check process or by subsequent staff administering the medication. Multiple staff members, including registered nurses and licensed practical nurses, were involved in the medication administration and order entry process. The error was not questioned until after the fourth dose had been given, at which point a nurse reviewed the medication and brought the issue to the attention of supervisory staff. Interviews revealed that staff assumed the order was correct, particularly because the resident was on hospice care, and did not verify the appropriateness of the dose or question the high dosage of morphine being administered. The resident, who had not previously received morphine at home, became unresponsive and died following the administration of the incorrect doses. Family members raised concerns about the resident's condition and the potential use of Narcan, but were advised by facility staff and a physician that Narcan was not appropriate or effective at that time. The facility's policies on medication administration and error reporting were not followed, and the error was only identified after significant harm had occurred.
Removal Plan
- Narcotic orders were reviewed for ongoing appropriateness and safety by Medical Director #1.
- Narcotic orders were reviewed for ongoing appropriateness and safety. Immediate education was provided to Physician #1 and Licensed Practical Nurse #1, and the order was amended by Chief Nursing Officer #1 and Medical Director #1.
- All active medication orders were reviewed by the consultant pharmacists and medical director for ongoing appropriateness and safety.
- Administrator #1 worked with electronic ordering system creators to enable a feature to run reports that reflected ordering errors for closer daily monitoring.
- All on-call physicians and nurse practitioners were in serviced by the Medical Director #1 regarding high-risk medications and review of electronic ordering for safe dosing.
- The remaining physicians and nurse practitioners were inserviced.
- ‘Transcription of Orders' policy was developed to include information regarding medication reconciliation as well as the triple check process.
- Compared transcribed orders with original provider order for accuracy. Checks were completed and documented in the paper chart for the next two consecutive shifts.
- All nursing including agency staff will be educated by nursing educator/designee prior to start of shift on the updated Medication Error Reporting policy, which includes directions on provider and family notification as well as resident monitoring and documentation requirements.
- Education Sign-In Sheets titled Transcription- Triple Check- Medication Reconsolidation, Transfer report - hand off sheet, Neglect related to Resident Monitoring - Education sign-in sheets documented in house nurses and agency nurses educated. Agency nurses left to educate if they return to the facility.
- Chief Nursing Officer #1 stated that the medication nurse was educated regarding an end date needed for the order and printing orders to place in the chart to begin the triple check process.
- Medical Director #1, and/or Administrator #1 and/or Chief Nursing Officer #1 would check orders from the previous day.
- Nurse Managers were responsible for completing audits on triple check and would bring audit results to Quality Assurance monthly meetings.
- Surveyors verified the facility conducted a daily 24-hour look back on all new medication orders by Director of Nursing #1 or designee.
- Interviews with all parties responsible for these barrier checks showed they were aware of their required responsibilities.
Failure to Prevent Neglect and Respond to Opioid Overdose
Penalty
Summary
A facility failed to protect a resident from neglect, resulting in the administration of four incorrect doses of morphine sulfate totaling 80 milligrams over a 12-hour period. The resident, who was admitted for respite care with diagnoses including dementia, end-stage renal disease, and atrial fibrillation, had not previously received morphine at home. The error originated from a transcription mistake during the medication reconciliation process, where three out of five morphine orders were entered incorrectly and the facility's triple check system was not fully completed, lacking a third verification signature. The error was discovered only after a nurse questioned the order, at which point the incorrect order was discontinued and a corrected order was entered. Following the medication error, the resident became lethargic and unresponsive, with unstable vital signs including low blood pressure and oxygen saturation. Despite these changes, there was no documented evidence that the facility provided interventions to reverse the effects of the opioid overdose, such as administering naloxone (Narcan), even after the family inquired about it. Additionally, there was a lack of documented monitoring, assessment, or treatment for the resident's decline after the error was identified. Vital signs and nursing assessments were not consistently recorded, and there was no evidence of physician oversight or coordination with hospice regarding the medication error. Communication failures further contributed to the deficiency. The resident's representative was not notified of the medication error until after the resident's condition had significantly deteriorated. Hospice was not informed of the medication error, and attempts to contact hospice during the resident's decline were unsuccessful due to incorrect contact information. Key facility leadership, including the Director of Nursing and Administrator, were not promptly informed of the incident, and staff interviews revealed a lack of awareness and documentation regarding the resident's condition and the actions taken. The resident ultimately expired without documented evidence of appropriate monitoring or intervention following the overdose.
Removal Plan
- Post Hospice contact information in each nursing unit and include on the face sheet for residents actively on Hospice.
- Make the contact for Community Hospice visible at accessible locations such as a nursing station on each resident unit.
- Ensure that for all residents enrolled in Hospice services, the contact number for Community Hospice is visible and accessible under contacts on the residents' face sheets in both electronic and paper charts.
- Update medication error reporting policy to require the Physician/Nurse Practitioner, upon notification of medication error, to provide direction for monitoring, duration of monitoring, and expected follow up communication.
- Require documentation of the nature of the incident, individuals notified (including family and hospice as applicable), actions taken, orders received, results of continued monitoring, assessments, and communication.
- In-service all on-call Physicians and Nurse Practitioners regarding high-risk medications and review of electronic ordering for safe dosing.
- Educate all nursing staff, including agency staff, by the nursing educator/designee on the updated Medication Error Reporting policy, including directions on provider and family notification as well as resident monitoring and documentation requirements.
- Use education sign-in sheets to document that in-house and agency nurses were educated; educate remaining agency nurses if they return to the facility.
- Compare transcribed orders with original provider order for accuracy; complete and document checks in the paper chart for the next two consecutive shifts.
- Educate all nursing staff (including agency staff) by the nurse educator, supervision, or designee regarding medication reconciliation, medication transcription, triple check, and safe medication administration practices.
- In-service all in-house and agency nurses regarding the abuse/neglect and mistreatment policy, with a special focus on potential neglect related to medication errors and lack of monitoring, assessment, and documentation related to change in condition.
Failure to Ensure Safe Discharge and Continuity of Care for Resident with Diabetes
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident with diabetes and diabetic wounds, resulting in Immediate Jeopardy. The resident, who was homeless and had no identification, was discharged to the Department of Social Services via family transportation without prior consultation with the Department to confirm the availability of housing or supportive services. The discharge planning process did not include verification that the resident's health and safety needs or preferences were met, and there was no evidence that the resident or their representative received or signed discharge instructions. The resident was discharged without proper education or supplies to manage their diabetes and diabetic wounds. Documentation was lacking regarding the provision of insulin, a glucometer, or wound care supplies, and there was no record of medication reconciliation or teaching for diabetes management. Interviews with facility staff revealed confusion about responsibilities for discharge education and supply provision, and it was confirmed that the resident did not have a primary care provider established at the time of discharge, which prevented the setup of home health or wound care services. After discharge, the resident was denied emergency housing at the Department of Social Services due to a previous unpaid stay and had to rely on their sibling for temporary accommodation and basic needs such as food. The resident subsequently presented to the emergency department with dangerously high blood sugar, having been discharged from the facility without insulin or medications sent to a pharmacy. Interviews with staff and the resident's family confirmed that the resident was not adequately prepared or equipped for self-care post-discharge, and that the facility's discharge process failed to ensure continuity of care or resident safety.
Removal Plan
- The pending discharge was reviewed for verification of post-discharge services, receiving locations, and physician notification.
- Social Services, the Nursing Management team involved in discharges, Director and Assistant Director of Rehabilitation, and the Recreation Director were educated on discharge planning process to include verification of safety and discharge medication.
- A new discharge form was instituted that required medication listed with quantities, medical equipment provided, teaching provided, and discharge location that required both resident/resident representative signature in addition to discharging nurse.
- All discharges in the last 30 days were reviewed for safety and called to ensure they had the necessary services in place.
- All staff identified for education received education, with the exception of staff members who were not available. The individuals who did not receive education will complete education upon their return, prior to the start of their shift.
- Interviews were completed to determine compliance with staff training and education including the Director of Social Services, the Recreation Director, the Assistant Director of Rehabilitation, one Unit Manager, and the Director of Nursing.
Failure to Prevent Choking Death Due to Inadequate Supervision and Aspiration Precaution
Penalty
Summary
A deficiency occurred when a severely cognitively impaired resident, who was at risk for aspiration and choking and required supervision during meals, was found unresponsive in a hallway late at night. The resident had a documented history of wandering, taking other residents' food, and required a puree and nectar thick liquid diet with soft sandwiches. The resident wore a green charm indicating aspiration risk and was supposed to be closely supervised, especially during meals and when in common areas. Despite these precautions, the resident was last seen in the hallway and was later found unresponsive in their wheelchair with food, including peanut butter and meat, lodged in their airway. Staff interviews and documentation revealed that the resident was not being adequately supervised at the time of the incident. Certified Nursing Assistants and nurses on duty were either unaware of the resident's whereabouts or did not recognize the need for immediate intervention when food was observed in the resident's mouth. The staff did not perform appropriate emergency measures such as suctioning the airway, and there was confusion about the timeline and actions taken during the emergency response. The facility's policy required close observation and intervention for residents with aspiration risk, but these protocols were not followed, as evidenced by the lack of supervision and failure to prevent the resident from accessing and consuming unsafe food. The incident resulted in the resident's death due to choking and aspiration, as confirmed by emergency medical services who found large amounts of food obstructing the airway. The facility's documentation and staff statements indicated gaps in monitoring, supervision, and adherence to established aspiration precautions. The deficiency was identified as Immediate Jeopardy due to the actual harm and death of the resident and the potential for serious harm to other residents at risk for aspiration.
Removal Plan
- Hold a Quality Assurance Performance Improvement meeting addressing the immediate jeopardy citation (F689), root cause and scope determination, immediate corrective actions, directed plan of correction and monitoring and validating plan.
- Reeducate the Nursing staff, Dietary and Speech Therapists regarding resident safety and supervision, aspiration precautions and emergency response.
- Conduct a chart audit on residents to ensure residents are assessed for aspiration and wandering behavior. Implement physicians' orders and update care plans.
- Review Policies and Procedures on Cardiopulmonary Resuscitation and Heimlich Maneuver.
- Revise the Cardiopulmonary Resuscitation policy and procedure to include not to move the resident to the bed or another area, begin cardiopulmonary resuscitation where the resident is found.
- Revise the Heimlich Maneuver policy and procedure to include to lower resident to a firm surface and activate Emergency Medical Service (911), begin cardiopulmonary resuscitation starting with compressions, before delivering breaths during cardiopulmonary resuscitation cycles, open mouth and look for visible object, remove only if seen, do not perform blind finger sweeps.
- Reevaluate all locations of nourishment and snacks on the units to ascertain if current measures to secure said nourishment is adequate.
- Initiate in-service education to Certified Nursing Assistants, Licensed Nurses, Speech Therapist and Dieticians regarding residents at risk for aspiration, facility safety practices, policy update, rounding and documentation, and environmental safety measures.
- Provide staff in-service on resident safety and supervision, aspiration precautions and emergency response.
Failure to Prevent Falls and Provide Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of effective interventions to prevent accidents and falls for two residents with cognitive impairment and a history of frequent falls. One resident with severe dementia experienced five unwitnessed falls over a period of time, with the facility failing to update or modify care plan interventions after each incident. The interventions remained limited to environmental reminders, such as signage and call bell placement, despite the resident's known tendency to self-transfer and not use the call bell. Staff interviews confirmed that the resident was impulsive, required assistance with transfers, and was becoming increasingly weak, yet no new or enhanced interventions were documented or implemented following repeated falls. On one occasion, the resident was found unresponsive, unclothed, and cold on the floor of their room after an unwitnessed fall. The resident's body temperature was unmeasurable, oxygen saturation was critically low, and they were subsequently hospitalized with hypothermia, acute respiratory failure, and septic shock, ultimately resulting in death. Staff interviews revealed that the resident was not being monitored more frequently despite illness and a history of falls, and there was no formal protocol for increased checks or rounding for high-risk residents. Documentation showed that staff were not provided with additional training or guidance following the incident, and care plans were not revised to address the ongoing risk. A second resident with moderate cognitive impairment and Parkinson's disease sustained 30 falls, 20 of which were unwitnessed, over a documented period. The care plan lacked active interventions for transfer and ambulation status, and there was no evidence of monitoring the effectiveness of interventions or modifying them as necessary. Staff interviews indicated that there was no formal rounding protocol or increased monitoring for residents with repeated falls. The facility's own policies required aggressive monitoring and intervention for high-risk residents, but these were not followed, resulting in substandard quality of care and actual harm.
Removal Plan
- Reviewed fall care plans for residents identified as having a high risk for falls.
- Reviewed care Kardex for residents identified as having a high risk for falls.
- Educated staff on the systematic changes and policy review (accidents and incidents prevention, investigation, hourly checks, communicating to the emergency management system and hospital system).
- Educated all active employees on these systemic changes and policy reviews.
- Ensured no staff reported to active duty without having this education.
- Held a Quality Assurance Performance Improvement meeting.
- Educated Certified Nurse Aides, Licensed Practical Nurses, and Registered Nurses regarding the new policy involving hourly checks for residents identified as increased risk for falling.
- Certified Nursing Assistants documented completion of hourly checks for the identified residents in a binder at the nursing station.
- Nursing staff verified completion of this task at shift completion.
- All staff interviewed verbalized understanding of the new policy and procedures involving hourly rounding on residents identified as having a high risk for falls.
Failure to Provide Timely Pressure Ulcer Assessment and Care
Penalty
Summary
A resident with multiple sclerosis, depression, and generalized weakness, who was cognitively intact, experienced a significant lapse in pressure ulcer care following a hospital admission for stroke-like symptoms. Upon return to the facility, the resident had a sacral wound with specific wound care instructions from the hospital, but there was no documented evidence that new wound care orders were entered or that the wound was properly assessed and treated from the time of readmission through several weeks. Nursing documentation was inconsistent, with gaps in dressing changes, skin checks, and provider assessments. The wound was not seen by a provider or the wound care team for an extended period, despite staff being aware of the open area and pain reported by the resident. The facility's policy required comprehensive skin assessments, weekly skin checks, daily visual checks by CNAs, and prompt notification and documentation of new skin issues. However, these protocols were not followed. Staff failed to notify the wound care team or medical providers in a timely manner, and incident reports were not consistently initiated for new or worsening wounds. Communication among staff was fragmented, with some nurses and providers unaware of the resident's condition or missing documentation of assessments and interventions. The resident's wound deteriorated from a Stage 1 to a Stage 4 pressure injury, with increasing pain and signs of infection, ultimately requiring sharp debridement during a subsequent hospitalization. Interviews with staff revealed confusion about reporting requirements, inconsistent practices regarding skin checks and incident reporting, and missed opportunities for timely intervention. The resident reported prolonged periods in bed due to lack of assistance, contributing to the worsening of the wound. Observations confirmed that pain was not addressed during wound care. The cumulative failures in assessment, documentation, communication, and timely intervention resulted in actual harm to the resident and placed other residents with pressure ulcers at risk for serious harm.
Removal Plan
- All residents with pressure ulcers were reassessed and treatment plans were reviewed for appropriateness.
- The Skin Care Program policy and procedure was revised to include all new admissions and readmissions would be screened by a member of the wound care team to ensure appropriate skin care treatment plan was initiated.
- Wound Care staff received re-education on the revised policy and procedure.
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